﻿<%@ Page Title="" Language="vb" AutoEventWireup="false" MasterPageFile="~/Site.Master" CodeBehind="accMaster.aspx.vb" Inherits="OAR.accMaster" %>
<asp:Content ID="Content1" ContentPlaceHolderID="HeadContent" runat="server">
</asp:Content>
<asp:Content ID="Content2" ContentPlaceHolderID="FeaturedContent" runat="server">
    <p>
        <strong>4. EMPLOYMENT RECORD</strong></p>
    <p>
        &nbsp;
        Worker&#39;s NRC&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
&nbsp;&nbsp;<asp:TextBox ID="tb_workerNRC" runat="server" AutoPostBack="True"></asp:TextBox>
        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Worker&#39;s Name&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<asp:TextBox ID="tb_workerName" runat="server"></asp:TextBox>
        &nbsp;&nbsp;&nbsp;
    </p>
    <p>
        For how long has s/he been your worker?&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_lengthServiceYears" runat="server"></asp:TextBox>
&nbsp;(Years)&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_lengthServiceMonths" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp; (Months)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_lengthServiceWeeks" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp; (Weeks)</p>
    <p>
        IIf not your direct employee, give :</p>
    <p>
        Name of subContractor&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_subContractorName" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Address of subContractor&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_subContractorAddress" runat="server" Width="251px"></asp:TextBox>
    </p>
    <p>
        Prior to this accident, had s/he to your knowledge any physical defect or suffer from any serious disease? (Y/N)&nbsp;<asp:RadioButtonList ID="rbl_priorDefect" runat="server" RepeatDirection="Horizontal">
            <asp:ListItem Value="Y">Yes</asp:ListItem>
            <asp:ListItem Value="N">No</asp:ListItem>
        </asp:RadioButtonList>
    </p>
    <p>
        If yes give details&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_priorDefectDetails" runat="server" Width="675px"></asp:TextBox>
    </p>
    <p>
        <strong>5. EARNINGS</strong></p>
    <p>
        a) Basic Wages, excluding bonus, commission or allowances (please enter just one category)</p>
    <p>
        Per Hour&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_basicWageHour" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp; Per Shift&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_basicWageShift" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp; Per Week&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_basicWageWeek" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp; Per Ticket&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_basicWageTicket" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp;
    </p>
    <p>
        Per Month&nbsp;
        <asp:TextBox ID="tb_basicWageMonth" runat="server"></asp:TextBox>
    </p>
    <p>
        b) Normal working hours (please enter just one category)</p>
    <p>
        Per Week&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_workingHoursWeek" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp; Per Shift&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_workingHoursShift" runat="server"></asp:TextBox>
    </p>
    <p>
        <strong>6. PREVIOUS ACCIDENT RECORD</strong></p>
    <p>
        a) Has s/he previously received compensation for permanent disablement? (Y/N)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
        <asp:RadioButtonList ID="rbl_previousCompensation" runat="server" RepeatDirection="Horizontal">
            <asp:ListItem Value="Y">Yes</asp:ListItem>
            <asp:ListItem Value="N">No</asp:ListItem>
        </asp:RadioButtonList>
        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
    </p>
    <p>
        b) If yes, when was s/he employed&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_previousEmploymentDate" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp; and by whom ?&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_previousEmployer" runat="server" Width="279px"></asp:TextBox>
    </p>
    <p>
        <strong>7. CURRENT ACCIDENT</strong></p>
    <p>
        a) Where did it occur ? (State site e.g workshop, underground etc)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_accidentSite" runat="server" Width="346px"></asp:TextBox>
    </p>
    <p>
        b) When did it occur ?&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_accidentDate" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Time&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_accidentTime" runat="server"></asp:TextBox>
    </p>
    <p>
        c) When did the worker report it?&nbsp;&nbsp;&nbsp; Date&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_dateAccidentReported" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Time&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_timeAccidentReported" runat="server"></asp:TextBox>
    </p>
    <p>
        d) If s/he failed to report it on the same day, what is the explanation ?</p>
    <p>
        <asp:TextBox ID="tb_nonReportExplain" runat="server" Width="828px"></asp:TextBox>
    </p>
    <p>
        e) Describe how the accident happened</p>
    <p>
        <asp:TextBox ID="tb_accidentDescription" runat="server" Width="821px"></asp:TextBox>
    </p>
    <p>
        f) Did it result from action properly within the scope of the worker&#39;s duties?&nbsp;(Y/N)&nbsp;
        <asp:RadioButtonList ID="rbl_accidentResult" runat="server" RepeatDirection="Horizontal">
            <asp:ListItem Value="Y">Yes</asp:ListItem>
            <asp:ListItem Value="N">No</asp:ListItem>
        </asp:RadioButtonList>
    </p>
    <p>
        IIf not, please provide explanatory statement</p>
    <p>
        <asp:TextBox ID="tb_accidentResultStatement" runat="server" Width="816px"></asp:TextBox>
    </p>
    <p>
        <strong>8. CAUSE OF ACCIDENT</strong></p>
    <p>
        a) Was Accident caused by (Y/N):
    </p>
    <p>
        Deliberate violation of rules/regulations?&nbsp;
        <asp:RadioButtonList ID="rbl_accidentViolation" runat="server" RepeatDirection="Horizontal">
            <asp:ListItem Value="Y">Yes</asp:ListItem>
            <asp:ListItem Value="N">No</asp:ListItem>
        </asp:RadioButtonList>
&nbsp;&nbsp;&nbsp; Drunkenness?&nbsp;
        <asp:RadioButtonList ID="rbl_accidentDrunk" runat="server" RepeatDirection="Horizontal">
            <asp:ListItem Value="Y">Yes</asp:ListItem>
            <asp:ListItem Value="N">No</asp:ListItem>
        </asp:RadioButtonList>
&nbsp;&nbsp;&nbsp; Deliberate contravention of any law ensuring safety?
        <asp:RadioButtonList ID="rbl_accidentContravention" runat="server" RepeatDirection="Horizontal">
            <asp:ListItem Value="Y">Yes</asp:ListItem>
            <asp:ListItem Value="N">No</asp:ListItem>
        </asp:RadioButtonList>
    </p>
    <p>
        IIf any reply is in affirmative, please provide explanatory statement</p>
    <p>
        <asp:TextBox ID="tb_accidentCauseStatement" runat="server" Width="818px"></asp:TextBox>
    </p>
    <p>
        b) Witness to the accident</p>
    <p>
        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        Name&nbsp;
        <asp:TextBox ID="tb_accidentWitness" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp; Address&nbsp;
        <asp:TextBox ID="tb_accidentWitnessAddress" runat="server" Width="383px"></asp:TextBox>
&nbsp;&nbsp;Tel/Cell Nbr&nbsp;
        <asp:TextBox ID="tb_accidentWitnessTelNbr" runat="server"></asp:TextBox>
    </p>
    <p>
        c) Was the accident caused by the action of a person other than the worker? (Y/N)&nbsp;&nbsp;&nbsp;
        <asp:RadioButtonList ID="rbl_accidentOtherAction" runat="server" RepeatDirection="Horizontal">
            <asp:ListItem Value="Y">Yes</asp:ListItem>
            <asp:ListItem Value="N">No</asp:ListItem>
        </asp:RadioButtonList>
    </p>
    <p>
        IIf yes, give the following details:</p>
    <p>
        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        Name&nbsp;
        <asp:TextBox ID="tb_accidentOtherActionName" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp; Address&nbsp;
        <asp:TextBox ID="tb_accidentOtherActionAddress" runat="server" Width="379px"></asp:TextBox>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Email
        <asp:TextBox ID="tb_accidentOtherActionEmail" runat="server"></asp:TextBox>
    </p>
    <p>
        Tel/Cell Nbr&nbsp;
        <asp:TextBox ID="tb_accidentOtherActionTelNbr" runat="server"></asp:TextBox>
    </p>
    <p>
        <strong>9. OTHER OFFICIAL INQUIRIES</strong></p>
    <p>
        a) Has notice been received of any magisterial or other official inquiry?&nbsp;(Y/N)&nbsp;&nbsp;
        <asp:RadioButtonList ID="rbl_officialNotice" runat="server" RepeatDirection="Horizontal">
            <asp:ListItem Value="Y">Yes</asp:ListItem>
            <asp:ListItem Value="N">No</asp:ListItem>
        </asp:RadioButtonList>
    </p>
    <p>
        b) If the accident was investigated by the Police, state name of police station&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_policeStationName" runat="server" Width="396px"></asp:TextBox>
    </p>
    <p>
        <strong>10. PARTICULARS OF DISABLEMENT</strong></p>
    <p>
        a) Describe the nature and extent of the injuries sustained, mentioning parts of the body and in the case of limb or eye, stating right or left side</p>
    <p>
        <asp:TextBox ID="tb_natureOfInjury" runat="server" Width="865px"></asp:TextBox>
    </p>
    <p>
        b) When did the worker cease work as a result of the accident?</p>
    <p>
        Date (DD/MM/YYYY)&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_ceaseWorkDate" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Time&nbsp;(hh:mm)&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;
        <asp:TextBox ID="tb_ceaseWorkTime" runat="server"></asp:TextBox>
    </p>
    <p>
        c) State probable period worker will be off duty</p>
    <p>
        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        Months&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_monthsOffDuty" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; OR&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Weeks&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;
        <asp:TextBox ID="tb_weeksOffDuty" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; OR&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Days&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_daysOffDuty" runat="server" Width="100px"></asp:TextBox>
    </p>
    <p>
        d) Name of Doctor attending to worker&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_doctorName" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp; and their address&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_doctorAddress" runat="server" Width="355px"></asp:TextBox>
    </p>
    <p>
        e) If in hospital, name of hospital&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_hospitalName" runat="server"></asp:TextBox>
&nbsp;&nbsp;&nbsp; and its address&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_hospitalAddress" runat="server" Width="352px"></asp:TextBox>
    </p>
    <p>
        <strong>11. DECLARATION</strong></p>
    <p>
        I I hereby certify that to the best of my knowledge and belief, the particulars furnished in this report are true and correct.</p>
    <p>
        Name and Position&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
        <asp:TextBox ID="tb_reporterPosition" runat="server" Width="614px"></asp:TextBox>
    </p>
    <p style="margin-left: 320px">
        <asp:Button ID="bt_AccMaster" runat="server" Text="Save Accident Information" />
    </p>
</asp:Content>
<asp:Content ID="Content3" ContentPlaceHolderID="MainContent" runat="server">
</asp:Content>
